- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $2,454.71
| Facility | | $1,348.96 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $1,659.59
| Professional | | $1,096.48 | $1,202.26 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,949.84 / $2,344.23
| Professional | | $478.63 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,238.72
| Professional | | $1,023.29 | $1,445.44 | $2,238.72 |